1. Common Impairments with knee hypomobility
    • More loss of flexion than extension
    • Effusion (can be internal)
    • Joint assumes a position near 25 degrees of flexion (capsule)
    • Stiffness, pain, reflex quadriceps inhibition (extensor lag in active knee extension)
    • disturbed balance responses
  2. Common Functional Limitations with knee hypomobility
    • Pain with motion, with weight bearing, during gait which interferes with ADL's
    • Difficulty with sitting down, rising from chiar, descending or ascending stairs, stooping, and squatting,
    • Decreased gait distance
  3. Goals of the Maximal Protection Phase with knee hypomobility
    • Acute Phase
    • 1. Control Pain
    • 2. Maintain soft tissue and joint mobility
    • 3. Maintain muscle function and prevent patellar adhesions
    • 4. Protect the Joint
  4. How to Protect the Joint in the Maximal Protection Phase with knee hypomobility
    • Partial weight bearing activities (assistive devices)
    • Pt Education - bed positioning to avoid flexion contractures
    • Make functional Adaptations - minimize stair climibing, use elevated seats, avoid deep seated or low chairs
  5. Goals Of Controlled Mobility Phase and Return to Function Phase with knee hypomobility
    • 1. Decrease the effects of stiffness and inactivity
    • 2. Decrease pain from mechanical stress
    • 3. Increase joint play and ROM
    • 4. Develop strength and endurance in supporting muscles
    • 5. Improve function
    • 6. Pt Eduction
  6. Pt Education in Return to function phase with knee hypomobility
    • What to expect from recovery
    • How to protect joints
    • emphasize that maintaining strength in suppoerting muscles helps protect and stabilize the joint
    • Do ROM and isometrics prior to standing
    • Alternate activity with rest
    • Chair exercises
  7. Primary reason for TKA
    • Elminate severe pain
    • Restore ADL function in patiens with OA and RA
  8. Contraindications for TKA
    • Active sepsis
    • Prior knee infection
    • Absent quadriceps function
  9. Pre-operative training for TKA
    • Attend pre-op joint class
    • PT consult
    • Gain functional activity assessment/ training
    • Home assesment
    • Blood donations
  10. TKA surgery info
    • Strong enough to hold 1000 lbs
    • Most common materials ued are cobald chromium or titanium
    • 2-3 hrs in OR
    • Can be stabilized with or without cement
    • No cement increases weight bearing percautions
  11. Complications of TKA
    • DVT
    • Pulmonary Embolus
    • Infection
    • Patellofemoral problems
  12. Precautions for TKA
    • Weight bearing status determined by physician
    • May wear knee immobilizer post op
  13. TKA rehabilitains involements
    • Education
    • Reconditioning
    • Restoring ROM
    • Gait Training
    • PTA needs to be aware of differnt types of TKA's and any special precautions
    • Treatment will being afternoon of surgery or the next morning
    • BID
    • 2-3 days in hospital
  14. Etiology of Symptoms for Patellofemoral Dysfunction
    • Direct Trama
    • Overuse
    • Faulty patellar tracking from malalignment due to anatomic variations or soft tissue imbalances
    • Degeneration
    • A combination of these factors
  15. Common Impairments form Patellofemoral Dysfunction
    • Weakness inhibition or poor recruitment or timing of firing of the VMO
    • Overstretched medial retinaculum
    • Restricted lateral retinaculum, IT badn or facial structures around patella
    • Pronated foot
    • Tight gastroc/soleus, hamstring or rectus femoris
  16. Important Rehab Considerations with Patellofemoral Dysfunction
    • Stress to the articualting surface of the patella varies during ROM
    • Little or no contact from 0-15 degrees of flexion
    • Greatest patellar stress is at 60 degress and compression loads at 75 degrees
    • Where pathology is located will affect which portion of the range is felt
    • Don't exercise Mid range
  17. Nonoperative management - Maximun Protection phase for Patellofemoral Dysfunction
    • Modalities
    • Gental motion
    • Isometrics in pain free positions
    • Rest - reduce irritating forces, brace or tape to unload joint
  18. Goals for Controlled Mobility and Return to Function Phases with Patellofemoral Dysfunction
    • 1. increase flexibility of the laterla facia and insertion of the IT band
    • 2. Stretch out tight structures
    • 3. Strengthen knee extension in nonweightbearing poition and weightbearing position (not in mid range)
    • 4. Modify biomechanical stresses (fix pronated feet)
  19. Surgery options for Patellofemoral Dysfunction
    • Alter the alignment of the PF joint
    • Correct soft tissue imbalances
    • Decrease an abnormal Q angle
    • Debride the articular surface of the patella
    • Release of the lateral Reinaculum (LRR)
    • Chondroplasty
    • Abrasion arthroplasty
    • Proximal or distal realignment of the extensor mechanism
    • Patellectomy
  20. Clinical Presentation of Knee Sprain
    • May be edematous - following trauma the joint usually does not swell for several hours
    • Painful with palpation to injury ligament
    • May not be able to bear weight with ambulation
    • May have hypermobility when testing joint play or ligamentous stability
  21. Import Rehab Consideration for Ligamentous Injuries
    • With ACL injuries
    • Avoid open chain knee extension from 0-60 with resistance and squatting from 60-90 degrees
    • Too musch stress on ligamnt
    • Focus on Hamstring Strength
  22. ACL Autograft
    • Most common
    • the central 3rd of patellar tendon along with a segment of bone from the patella and the tibia or hamstring graft are used
    • 4-9 months grafted tendon revascularized and adopts the properties and function of old ligament and can achieve tenile strenght of orginal ACL
  23. Allograft ACL
    • Donor tiddue or cadaver to replace the injured tissue of the client
    • 60-75% success
  24. Precautions for ACL
    • Avoid resisted open chain terminal knee extension (especially from 0-20 degrees
    • Avoid Closed chain extension between 60-90 degrees
    • Contraction fo the quad in these positions and ranges causes the greates anterior tibial tranlation and can createe potentially excessice stress to the graft
    • Resisted knee flexion such as hamstring curls are postponed until 9-10 weeks post-op to avoid stressing graft
    • When gpressing to work on sport related activites pt should avoid activites that place excessive posterior forces on the knee (deep squatting or walking down inclines)
  25. ACL postoperative management
    • Immobilization and protective bracing
    • Surgeon's determination
    • Controlled motion brace initially locked in extension or 5-10 degrees of flexion to prevent inadvertent hyperextension
    • Weight bearing 25-50%
    • Brace allowing motion from 0-125 degress may need to warm for 2-3 months
    • full weightbearing 3-4 wks if pain free
  26. Goals of the Maximun Protect Phase with ACL repair
    • 1. Prevent reflex inhibition and atropy of LE muscules
    • 2. Regain mobility within a protected range and prevent contractures of the knee
    • 3. Begin to resotre dynamic control of knee muslces (motor control, balance)
  27. Goals of Controlled Mobility with ACL repair
    • Begins 4-5 weeks at the point when pain and joint swelling are controlled
    • 1. regain full ROM of knee
    • 2. Increase strength, control, and endurance in LE
    • 3. Improve Proprioception and balance
    • 4. Regain cardiovascular fitness
  28. Goals of Return to Function with ACL repair
    • Generally begins at 10-24 weeks
    • Ephasis is on incorporating progressively demanding functional acitivties
    • By 24 weeks should be at per-injury level
  29. Common Impairments with Mensicus Tear
    • Can cause an acute locking of the knee and chronic symptoms with intermittent locking
    • Knee does not fully extend, springy end feel when passive extension attempted
    • Pain occurs along the joint line
    • Joint swelling (slight limit in flexion and extension)
    • Some degree of quad atrophy
  30. Nonoperative Management for Mensicus Tear
    • Unlocking may happen spontaneously or Pt can love leg to unlock it
    • Treat acute symptoms
    • Exercises should be performed in open and closed chain positions to imporve strength and endurance in isolated muscle groups and to prepare Pt for functional activites
  31. Surgical Management of Mensicus tear
    • retain as much of menisucs as possible
    • repair or partial menisectomy
    • Total menisectomy
    • Repair done if lesion occurs on outer 1/3 of the medial or lateral meniscus
  32. Mensicus precautions after repair
    • Knee typicall immobilized in full extension brace immediately after surgery
    • Controlled motion 0-90 for 4-6 weeks avoid excessive motion and suture site
    • Weightbearing restricted until 6-8 wks
  33. Goals for Maximum Protection phase after Mensicus Repair
    • Minimze atrophy and reestablish neuromuscular control of knee
    • Maintain strength in hip musculature
    • Regain Mobility
  34. Goals for controlled mobility phase after a mensicus repair
    • Progress ROM
    • maintain flexibility
    • increase strength and dynamic control
    • increase muscular endurace
    • re-establish balance
  35. Goals for Return to Function Phase after mensicus repair
    • Progress strengthening
    • improve cardio respiratory status
    • restore functional abilities
  36. Rehab Considerations for mensicus Tear
    • 1. Some limit CKC exercise until 8 weeks
    • 2. Full quatting or lunges should be avoided for at least 6 months
    • 3. Twisting, turning, and pivoting activities should be progressed cuatiously between 4-9 months to prevent excessive shear forces on the repaired menisucs
    • 4. Return to full activity varies but generally a minimum of 6 months is required for peripheral repair and 9 months for central repair
  37. Menisectomy/ Partial Menisectomy
    • Tears of the inner 2-3 (avascularportion) or the medial or lateral menisci
    • Post-op will have compression but no brace or immoblizer
    • Weightbearing as tolerated
    • No need to extend max protection phase
  38. Controlled Mobility Phase for Menisectomy/ Partial Menisectomy
    • Usually last 3-4 weeks
    • all exercises and weightbearing activites should be pain free and progessed gradually during the first few post op weeks
    • Initiate closed chain exercises and stationary bike to regain dynamic control and endurance of knee
  39. Return to function phase for Menisectomy/ Partial
    • 3-4 weeks post op
    • should achieve full AROM
    • resistance training
    • Endurance activites
    • Functional closed chain exercises in full weight bearing
    • Balance training
    • Advanced activities in 6-8 weeks
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